Catherine Arsenault

Background: Determinants of non-institutional delivery, particularly in the antenatal period, have been described previously, but less is known about the sequence of events during pregnancy and decision-making processes occurring between labour onset and birth. Aim: We explored reasons for non-institutional births and pathways leading to home and in-transit deliveries in a north Indian setting, with the aim of identifying context-specific, actionable recommendations. Methods: Participants were women from the north Indian site of the Redefining Maternal Anemia in Pregnancy and Postpartum (ReMAPP) cohort who experienced non-institutional delivery. We conducted an exploratory qualitative study using a semi-structured in-depth interview guide. An a priori conceptual framework was developed based on existing continuum-of-care literature and structured around the antenatal, intrapartum, and postnatal phases of care. The framework focused on the “decision-to-delivery pathway” and was subsequently iteratively refined and elaborated based on the thematic findings. Findings: Of the 2000 women enrolled at the north Indian site of the ReMAPP study, 75 (3.8%) experienced non-institutional delivery; among these, 50 participants were interviewed. Among those interviewed, 19 had planned, and 31 had unplanned non-institutional deliveries. Themes identified for planned non-institutional deliveries included perceived mistrust in healthcare, institutional avoidance, reliance on informal maternity care systems, and decision-making uncertainty. For unplanned non-institutional deliveries, themes included intention to institutional delivery, delay in obtaining appropriate maternity care, physical access barriers, reliance on informal birth assistance, and opportunities to avail health system services for post-delivery or newborn care. Conclusions: Our findings suggest that improving institutional delivery coverage requires more than physical access to facilities. Trust, respectful maternity care, timely responsiveness during labour, and birth preparedness appear to strongly influence whether women are able to reach and utilise institutional delivery services.

Background: Across the globe, rates of depression and anxiety have risen substantially since the COVID pandemic. Consequently, poor mental health is now a top health policy priority in many countries and more people than ever are seeking treatment. While the segment of people with poor mental health is large and growing, there is a dearth of data about their demographics and health needs and their use of and experience in the health system. Health systems require this information to effectively organize and provide services. Methods and findings: We investigated population prevalence of fair or poor mental health and compared health system experience and quality of care among adults with poor versus good mental health in 18 high-, middle-, and low-income countries using data from the People’s Voice Survey ( n = 32,419). Data were collected in 2022 and 2023 through a combination of nationally representative telephone, online, and in-person surveys. Prevalence of self-reported poor mental health ranged from 4.7% in Nigeria to 39.6% in China and was unrelated to national income per capita. More women than men reported poor mental health in most countries. Across all countries, people with poor mental health had worse self-rated overall health and more chronic illness. Between 0.9% (Lao PDR) and 52.4% (UK) of those with poor mental health had received mental healthcare in the past year. People with poor mental health reported lower patient activation, worse care quality, and lower confidence in the health system. A study limitation is that results are based on self-reported mental health rather than clinical diagnoses. Conclusions: People with poor mental health have markedly different health profiles and health system experience. These findings should prompt health systems to re-assess their services to better serve this growing patient group. Comparison of user experience and quality over time and across countries with similar health systems may assist in benchmarking performance.

Antenatal care (ANC) is crucial for maternal and newborn health. Although ANC coverage has improved globally, ANC quality remains suboptimal. This study assessed the quality of first ANC visits and their association with perinatal outcomes. We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy in Ethiopia, Kenya, South Africa, and India. Perinatal outcomes of interest included fetal losses (miscarriages ≥13 weeks of gestation or stillbirths) and low birth weight (LBW) newborns. Good quality ANC at first visits was defined as receiving six essential care components: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess associations between good quality ANC and perinatal outcomes, with sensitivity analyses where good quality ANC excluded ultrasound scans. Among 3,600 pregnant women followed until the end of pregnancy, 5.8% received all six components at their first visits (from 1.3% in India to 14.0% in Ethiopia), and 30.7% received five components (5.7% in India to 52.5% in Kenya). Between 3.7% of women in Ethiopia and 6.3% in India experienced a fetal loss. Between 8.5% of newborns in Ethiopia and 16.3% in India were born LBW. Good quality ANC at first visits was associated with a 32% to 59% lower risk of fetal loss (primary analysis: risk ratio (RR) 0.41, 95% confidence interval (CI) 0.10–0.72; sensitivity analysis: RR 0.68, 95% CI 0.44–0.92). No significant associations were observed between good quality ANC and LBW. This study identified important gaps in ANC quality and found that good quality ANC is associated with a lower fetal loss risk. Investments must be made to improve ANC quality and ensure the delivery of essential care in pregnancy.

Ethiopia has prioritised high-impact interventions to reduce neonatal deaths, including antenatal corticosteroids (ACS) utilisation. However, effective ACS use has faced various challenges. We used multiple data sources to examine the current landscape of ACS use in Ethiopia and to elucidate barriers to effective ACS utilisation, including a review of national obstetric guidelines over the past decade, a review of literature, and a descriptive analysis of health facility data. National obstetric protocols recommend administering ACS in both hospitals and health centres. However, ACS remains substantially underused. The 2016 Ethiopian Emergency Obstetric and Newborn Care Assessment reported that only 5% of preterm infants were born to women who had received corticosteroids before delivery. At the health facility level, the 2021 Ethiopian Service Provision Assessment survey showed that only 22.1% of facilities providing antenatal care and delivery services had administered ACS in the past 3 months, and 44.7% of facilities had injectable corticosteroids in stock at the time of the survey. Notably, private clinics had both the lowest corticosteroid availability (16.9%) and utilisation rate (2.8%). We identified several barriers to effective ACS use, including healthcare service delivery organisation, gaps in healthcare providers’ knowledge and skills (particularly at the primary healthcare level and in private facilities), challenges in accurate gestational age assessment resulting from limited access to early ultrasound and late initiation of antenatal care, and insufficient corticosteroid availability. Increasing ACS uptake alone is unlikely to have the desired population benefits without considering health service delivery redesign and integration with other life-saving maternal and newborn health interventions.

Background Undernutrition during pregnancy, including both micronutrient deficiencies and chronic energy deficiency, is an important public health concern with negative consequences for maternal, neonatal, and child health, development, and economic outcomes through the life course. Despite widespread efforts to address undernutrition during pregnancy, there is little evidence on the quality of management of maternal undernutrition in high-burden settings. Data on follow-up care for undernutrition over the course of pregnancy is particularly scarce. In this study, we used a novel longitudinal dataset to examine the quality of care for pregnant women with acute malnutrition and anemia in Ethiopia. Methods and findings We analyzed data from the Maternal and Newborn Health eCohort, a multi-country longitudinal study of the content, quality, and experience of maternity care during the prenatal, delivery, and postnatal periods. Data were collected in East Shewa in the Oromia region of Ethiopia from April 2023 to February 2024. Participants were recruited by research staff in a sample of health facilities at the time of their first antenatal care (ANC) contact and followed through delivery. Following Ethiopia’s national guidelines, acute malnutrition was defined as mid-upper arm circumference (MUAC) under 23 centimeters (cm), and anemia was defined as Haemoglobin (Hb) under 11 grams per deciliter (g/dL). We measured adherence to Ethiopia’s national guidelines for screening, prevention, and management of acute malnutrition, and conducted a longitudinal analysis using generalized estimating equations (GEE) to assess factors associated with adherence to iron and folic acid supplementation. 1000 women were enrolled in the eCohort. After excluding women who were lost to follow-up (n= 113), had miscarriages (n=29), or had missing information on nutritional status at baseline (n = 48), the analytic sample included 810 women. At the time of their first ANC contact, 22% of women in the sample had acute malnutrition and 11% had anemia. During the first ANC contact, only 12% of women were screened for acute malnutrition and 96% were screened for anemia. In follow-up care, weight monitoring according to national guidelines was performed for only 4% of women with acute malnutrition, and only 23% of women with anemia received the recommended number of blood tests. Only 11% of women with acute malnutrition ever received supplemental food during their pregnancy. While 89% of women with anemia were given or prescribed iron and folic acid supplements at some point during their pregnancy, only 32% took them throughout the entire pregnancy. Women with secondary education, women in the highest wealth quintile, women who reported past pregnancy complications, and women who received or were prescribed IFA supplements during the first ANC contact were more likely to adhere to IFA supplementation during pregnancy. Conclusions This study sheds light on striking gaps in the quality of care for undernutrition during pregnancy in Ethiopia. It is critical to identify approaches to improve the quality of care for undernutrition during pregnancy, focusing not only on screening and management at the first ANC contact but also on follow-up care through the remainder of pregnancy.

Non-communicable diseases like hypertension cause substantial morbidity and mortality in low- and middle-income countries, where limited access to high-quality care contributes to millions of preventable deaths annually. Traditional assessments of health system performance often rely on structural indicators and cross-sectional, overlooking patient experiences and care processes. In Latin America, amid rising cardiovascular disease, longitudinal tools are needed to guide improvements in healthcare delivery models, particularly for chronic diseases such as hypertension. The NCD e-Cohort is a prospective, longitudinal, mixed-mode (in-person and phone) survey designed to assess health system quality in Latin America. Developed by the QuEST Network, it integrates validated and locally tailored items aligned with the Lancet Global Health Commission's framework. Key domains include competent care, user experience, health outcomes, confidence in the health, economic impacts, and care pathways. About 600 hypertensive patients aged 35+ will be recruited from sentinel sites in Uruguay (CESCAS) and Peru (CRONICAS), with 300 participants per site. Data will be collected for one year, capturing real-time information on patient journeys and health system performance. This study advances hypertension care assessment by embracing the care-cascade approach and capturing dynamic patient-provider interactions, continuity, and treatment evolution. Although participant attrition may pose challenges, the frequent data collection minimises recall bias. The NCD e-Cohort will generate timely, actionable evidence to inform patient-centred policies and strengthen health systems in the region. Leveraging mobile technology enhances feasibility, scalability, and adaptability, potentially extending this approach to other chronic conditions.

Antenatal corticosteroids (ACS) utilization is disproportionately limited in low- and middle-income countries where most global preterm newborns who could benefit from this intervention are born. Understanding the factors affecting ACS use is crucial for improving its uptake. This study aimed to investigate facility-level factors associated with ACS use in low-resource countries. We used data from ten Service Provision Assessment surveys across nine countries. We restricted the sample to facilities that provided delivery services. Our primary outcome was recent ACS use, defined as having administered ACS within the past three months before the survey. We conducted mixed-effect log binomial regressions, with country as a fixed effect and sub-national regions as random intercepts, to explore the association between recent ACS use and facility characteristics, injectable corticosteroids and ultrasound availability, facility structural readiness, and past performance of nine Comprehensive Emergency Obstetric and Newborn Care (CEmONC) signal functions. A sensitivity analysis excluding the Afghanistan data was performed since the country adopted a different sampling strategy that mainly sampled urban facilities. This study included 6183 facilities from nine countries. Across eight countries with nationally representative data, only 22.7% (median, range 4.0% to 27.4%) of facilities that provided delivery services had used ACS recently, compared to 59.4% in the Afghanistan survey. Urban facilities had a 21% higher likelihood of recent ACS use (95% CI 6%–38%) than rural facilities. Corticosteroid availability was associated with a 14% higher likelihood of recent ACS use (95% CI 1%–29%). Facilities in the highest readiness tertile were more likely to have recent ACS use than those in the lowest (RR 1.91, 95% CI 1.58–2.30). Each CEmONC signal function, except assisted vaginal deliveries, was significantly associated with recent ACS use, with neonatal resuscitation having the largest effect (RR 2.62, 95% CI 1.93–3.55). In conclusion, facilities that had performed CEmONC services were more likely to administer ACS, highlighting the importance of provider knowledge, skills, and competence in managing obstetric and newborn emergencies for effective ACS provision.

Objective: The study aimed to evaluate healthcare use during the postnatal period for mothers and their babies, the content of care received, mothers’ perceived quality of care, and the factors influencing these perceptions. Methods: The study analyzed data from a postnatal survey conducted within the maternal eCohort at the Mexican Institute of Social Security (IMSS). The research involved 973 women aged 18–49 who were recruited following their first antenatal care visit with a family physician at 48 family medicine clinics across eight Mexican states. We described postnatal care (PNC) use, content of care and perceived quality and used Poisson multivariable regression analysis to investigate the factors influencing women’s perceptions of higher quality of care during PNC. Results: 29.4% of women and 12.0% of infants had no postnatal care visits within the six weeks following hospital discharge. Among women who received PNC, 72.3% accessed services exclusively through IMSS, 17.7% utilized a combination of IMSS and other providers, and 10% relied solely on private providers. Infants received 82.4% of recommended content of care, compared to 66.7% for mothers. The median perceived quality of care among women was 25 points on a scale of 8–40. Key areas for improvement include enhancing awareness of the importance of postnatal consultations among health personnel and women, reducing waiting times, and improving the content and length of consultations. Factors associated with better perceived quality included being over 35, receiving better content of care for infants, and being treated by private providers, while lower education levels, prior pregnancies, and poor health were associated with lower perceived quality. Conclusion: Improvements are needed to ensure all women and infants receive comprehensive postnatal care and to enhance patient-perceived quality.